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September 28, 2020

The Incompatibility of Patient-Centered Care With Fee-for-Service Payment

Author Affiliations
  • 1Department of Family Medicine, Oregon Health & Science University, Portland
JAMA Intern Med. 2020;180(12):1572-1573. doi:10.1001/jamainternmed.2020.4341

While still in residency, I met a patient in her early 90s with a history of colon cancer. Whenever I recommended surveillance tests, she told me to save Medicare dollars for younger people. She always expressed her appreciation for our team’s care, but she was matter of fact about how she had outlived her peers and did not want money or time spent on “frivolous tests.” When we noticed that her blood pressure was persistently high, despite her antihypertensive medication prescriptions, she accepted our offer to help manage daily medications. She started bringing a crumpled paper bag of medications to her visits. It was the same bag each time but with a different combination of pill bottles; many were outdated or had been discontinued. We were afraid that she was missing doses, but we also worried about the dangers of her taking extra pills or a lethal combination of medications. She came for monthly visits where we helped her fill pill containers for each day of the month. We also convinced her to discard expired and discontinued medications. I was still perplexed by the odd combination of bottles that kept appearing at these visits, so I arranged to visit her at home.

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    11 Comments for this article
    Right on!
    Paul Buehrens, MD, FAAFP | Retired FP from EvergreenHealth
    This piece articulates what most primary care practitioners have known for decades. Credit to the author, of course. The story is that of most primary care doctors. Now we have EHRs that only help as tools to code correctly for billing, and have been hijacked to that purpose as we make it harder and harder to practice good care like the author. The crying need is for national payment reform. Without that, it will be impossible to build the primary care based system that every patient wants and deserves.
    David Ginsburg, MD | CommunityHealth, Chicago
    I am very grateful to see this problem addressed so clearly. Primary care medicine is being suffocated by the antiquated fee for service system into which it has been confined. Dr. DeVoe gives an eloquent description of the potential of primary care for achieving the level of nobility to which we all once aspired. Unfortunately, she also makes clear why primary care, as currently practiced here in the U.S., so often fails to reach that level -- and the paradox in the current system's slavish devotion to a simplistic and inefficient economic model.
    Excellent review
    Arthur Sands, BS West Point, MD U of CO | Retired family physician
    The author is right on about the deficiencies in payment for vital services by primary care practitioners. In general, it seems like E&M code payments are lacking while procedure codes are well reimbursed. I think one of the solutions is direct primary care - which I would have done except this only became well known several years before I retired in 2017.
    There is no free lunch.
    Raphael Haciski, MD | Private practice, gynecology.
    I hate to be the fly in the ointment, but the saying that "there is no free lunch" comes to mind.

    It is admirable (and desirable) to give such full attention to a needy patient, but you have to consider what your salary is, and how that boils down to "per hour" cost. Spending all that time with a patient is admirable but who pays for that? Where is the money coming from? How do you sustain it financially?

    This can only be achieved in a "concierge" style of practice, which is why so many are
    trending that way. But you can only service a limited amount of patients, which leaves many other uncovered. I am not sure that "direct care" style would be sustainable at this level of involvement. I know of many group practices, where unless you see 4-8 patients per hour, you do not "pay for your existence" and will be relieved of your position for "underperformance."

    And money or not, there is a time factor. If you travel to patient's home and spend leisurely time chatting and reviewing their home situation and medications, you can not service more than 6-8 patients per day. Explain that to those who routinely see 20-30 patients in a work day (both because of the demand of patients in need, and the need to rationalize their existence and salary to the bean counters). It becomes a major obstacle.

    This is just a pipe dream, no matter how worthy. Rather than presenting your desirable work environment, it would be more productive to describe how we would manage this financially (and numerically).
    Direct Primary Care Physicians figured this out and are working to change this.
    Brian Pierce, MD | Megunticook Family Medicine
    Direct Primary Care (DPC), the affordable, simpler child of concierge medicine, is demonstrating we can stop waiting for payment reform for an effective payment model for primary care. That's no pipe dream as in the recent years over 1000 physicians have started DPC practices. Not only is DPC growing but, as this year's pandemic put many fee for service practices on financial life support, DPC's payment model proved very sustainable in tough economic times.

    We owe it to our patients to stop waiting for the government or other physician specialties to fix primary care.
    CONFLICT OF INTEREST: I own my own direct primary care (DPC) practice and cofounded a regional group for DPC physicians.
    Proper Fees Could Support Primary Care
    Steven Kanner, AB, MD, MSM, MACP | Independent primary care practice, Harvard hospitals affiliated
    We have all known for decades that fee schedules from Medicare and almost all other insurers are finely tuned to reimburse surgical procedures and tests, while insurance reimbursement for the discussion, counseling, supportive care, and preventive medicine that dominate primary care is grossly inadequate.

    Remember, just as one example, that the longest time period one can bill for is 40 minutes as a 99215 for an established patient. The Medicare reimbursement for that code does not cover the cost of our staff.

    Changing to a capitated model had been proposed as the solution (which would save enormous
    sums in billing costs), but inevitably the monthly pppm (per person per month) compensation is comically low.

    Our small practice in fact delivers robust primary care to our patients, including long visits, additional RN staff, and home visits, but we can only accomplish this because we have been a membership (concierge) practice for the past 14 years. The membership fee allows for the extensive staff and needed time to deliver our critical services.

    It remains unlikely that public or private insurers will ever provide adequate compensation, by any financial vehicle, to primary care. That is a true loss to everyone and underlies much of the unhappiness and high cost of our current medical care arrangements.
    The problem is the "service" definition, not the payment method.
    Robert Woodward, PhD | University of New Hampshire
    The problem with fee-for-service is more our inability to define "service" than it is to the payment method itself. Many of the "services" in a fee-for-service billing code are time-related and therefore equivalent to wages. Conceptually, output-based remuneration is the only system capable of providing incentives to ethical physicians to provide the right amount of care most efficiently. The two pre-conditions for such efficiency are 1) a comprehensive definition of "service" and 2) neither too many, nor too few patients being followed. Unfortunately, we really don't have anything close to appropriate service definitions. [Ref: Woodward R, Warren-Boulton F. Considering the Effects of Financial Incentives and Professional Ethics on ‘Appropriate’ Medical Care. Journal of Health Economics. 1984:3(3):223-237.]
    What you see and what you hear depends a great deal on where you are standing
    John Pfeiffer, MD | Retired
    “ ...while also decreasing the downstream costs.”

    The key word you used is “costs”. When you see “costs”, you’re thinking as a payer. That’s because you’re a primary care physician and you’re closely aligned with patients and seeing care from their point of view. OTOH, to almost everyone else who is providing care, i.e., the recipients of the other 95% of health care “spending”, that’s “downstream revenue”, and it’s what they see as your main purpose as a primary care “provider”, and the more of it you generate, the greater your value. The only way
    this will change is not just for primary care, but for the entire system, to change from fee-for-service to global capitation, full risk, population based, prospective payment, or whatever it’s being called this decade. Do that and watch how we suddenly stop doing unecessary and ineffective things and realize how primary care physicians have been exploited to keep the entire system solvent for decades.
    Medicare for all?
    Michael Mundorff, MBA, MHSA | integrated healthcare system
    This excellent article (perhaps inadvertently) highlights one of the problems with the current focus on the groundswell of support for “Medicare for all” plans. Covering the entire population using the same perverse reimbursement incentives will not result in better health for the population. Almost all other advanced nations have found a better way using a variety of systems. We just have to create the political will.
    Patient-Centered Care Also Incompatible With Medical Liability System: Health Courts Similar to Workers Comp Would Be Better
    Edward Volpintesta, MD | retired general practitioner
    There is no doubt that a trusting relationship between primary care physicians and their patients is of utmost value in providing humane, and cost effective care, whatever the medical problem may be, as the authors have shown. It is something that all good primary care physicians strive for even though they are not always successful. It was my goal for the 45 years I was in practice.
    But, unfortunately that trusting relationship doesn’t always develop—and I suspect that it happens with greater frequency—because doctors are too busy with time-consuming and distracting administrative chores to have any meaningful time left
    over to build trusting relationships.
    And without that trust, patients are often subjected to unnecessary and expensive tests and procedures because of fears of malpractice litigation and accusations brought by the family, alleging that the doctor wasn’t thorough.
    Clearly, patient-centered care at times is incompatible with fee-for-service. But it is equally incompatible with the medical liability system.
    Special health courts similar to workers comp have been proposed. They have great potential to improve the way medical litigation is dealt with, but they are rarely mentioned in the medical literature.
    Instantaneous understanding
    W Watson, MD.,CM., FACS, FRCSC |
    Unfortunately, telemedicine is driving the 'practice' of medicine in the wrong direction. Telemedicine is invaluable for rural areas and the far north. It can be a convenience for many visots in urban/suburban areas but is NOT a substitute for hands-on direct communication with patients.

    One can learn a great deal within seconds of entering a patient's home, just as watching a patient approach the consultation/examining room, the gait, stature, dress, mobility etc.

    When all else fails - listen to and examine the patient!!!

    This story illustrates the importance of learning how are patients live and the
    opportunity to communicate directly with thise they were living with, if not alone.

    I was a bit unusual in making house calls, but I found it very important in delivering care and a very rewarding pleasure.